Has a teacher or other supervisor commented that your child appears sleepy during the day?

NoYesDon't Know

Is it hard to wake your child up in the morning?

NoYesDon't Know

Does your child wake up with headaches in the morning?

NoYesDon't Know

Did your child stop growing at a normal rate at any time since birth?

NoYesDon't Know

Is your child overweight?

NoYesDon't Know

This child often...

Does not seem to listen when spoken to directly

NoYesDon't Know

Has difficulty organizing tasks

NoYesDon't Know

Is easily distracted by extraneous stimuli

NoYesDon't Know

Fidgets with hands or feet or squirms in seat

NoYesDon't Know

Is "on the go" or often acts as if "driven by a motor"

NoYesDon't Know

Interrupts or intrudes on others (e.g. butts into conversations or games)

NoYesDon't Know

This questionnaire is to evaluate for suspected sleep disordered breathing in your child. If 8 or more yes answers are marked a referral for a sleep evaluation is strongly indicated. Please feel free to ask any questions prior to or during completion if they should arise.